Managing Elder Abuse in Ireland: The Senior Case Worker’s Experience Deirdre O’Donnell, Margaret P. Treacy, Gerard Fealy, Imogen Lyons, Amanda Phelan, Attracta Lafferty, Jonathan Drennan, Suzanne Quin, Anne O’Loughlin
Managing Elder Abuse in Ireland: The Senior Case Workers Experience
Deirdre ODonnell, Margaret P. Treacy, Gerard Fealy, Imogen Lyons, Amanda Phelan,
Attracta Lafferty, Jonathan Drennan, Suzanne Quin, Anne OLoughlin
NCPOP Board of Programme Directors
Professor Margaret P. Treacy, Professor Gerard Fealy, Professor Denis Cusack, Professor Colm Harmon, Dr. Martin McNamara, Professor Cecily Kelleher, Ms Anne OLoughlin, Dr. Amanda Phelan, Professor Suzanne Quin
This study was funded by the Health Service Executive as part of the work of the National Centre for the Protection of Older People (NCPOP) at University College Dublin.
This report should be cited as ODonnell, D., Treacy, M.P., Fealy, G., Lyons, I., Phelan, A., Lafferty, A., Drennan, J., Quin, S., OLoughlin, A. (2012) Managing Elder Abuse in Ireland: Senior case workers experiences, NCPOP, University College Dublin.
National Centre for the Protection of Older People (NCPOP) UCD School of Nursing, Midwifery and Heath Systems
Health Sciences Centre University College Dublin Belfield, Dublin 4, Ireland
Tel: +353 (0)1 716 6467 Fax: +353 (0)1 716 6498 Email: [email protected] Web: www.ncpop.ie
UCD and HSE, 2012
Managing Elder Abuse in Ireland: The Senior Case Workers Experience
The authors are grateful to all the senior case workers who gave so generously of their time in providing the data on which this study is based. Without their engagement, the study would not have been possible.
The authors also wish to acknowledge:
The Health Service Executive which funds the National Centre for the Protection of Older People (NCPOP) and the programme of research, of which the study is part.
The HSE/NCPOP Management Group and the HSE/NCPOP Steering Group which advised on this study.
The National Elder Abuse Steering Committee of the Health Service Executive, which provided important support for the study.
Dr. Corina Naughton for her advice on aspects of the research design.
The NCPOP International Advisory Committee, comprising Professor Simon Biggs, Kings College London; Dr. Isabel Iborra Marmolejo, Queen Sofia Centre for Studies on Violence, Valencia, Spain, and Professor Karl Pillemer, Cornell Institute for Translational Research on Aging, Cornell University.
Ms. Judy Mathers, NCPOP Administrator for her support in the production of this report.
Managing Elder Abuse in Ireland: The Senior Case Workers Experience
Executive Summary i
Chapter 1 1Introduction
1.1 Background 1
1.2 Report Structure 1
1.3 International Developments in Response to Elder Abuse 1
1.4 The Irish Response to Elder Abuse 3
1.4.1 HSE Dedicated Elder Abuse Structures 3
Chapter 2 5Managing Elder Abuse in Practice
2.1 Introduction 5
2.2 Aims and Method of Literature Review 5
2.3 Detection and Referral 5
2.4 Investigation and Assessment 7
2.5 Intervention Strategies and Services Provision 8
2.5.1 Case Management 8
2.5.2 Monitoring 8
2.5.3 Counselling 9
2.5.4 Support Groups 9
2.5.5 Interventions for Caregivers 10
2.5.6 Home Support Services and Respite Care 10
2.5.7 Emergency Shelters, Refuges, Safe Houses and Long Term Care 11
2.5.8 Telephone Services 12
2.5.9 Daily Money Management (DMM) 12
2.5.10 Advocacy 12
2.5.11 Mediation, Conflict Resolution and Restorative Justice 13
2.5.12 Legal Intervention 14
2.5.13 Education, Information Provision and Advice 14
2.5.14 Multi-Component Interventions 15
2.6 Outcomes and Case Closure 15
2.7 Collaboration, Multi-disciplinary and Interagency Working 16
2.8 Decision-making in Elder Abuse Cases 17
2.8.1 Ethical Dilemmas and Challenges 18
2.9 Training, Supervision and Line Management 20
2.10 Conclusions 20
Chapter 3 22Research Design
3.1 Introduction 22
Managing Elder Abuse in Ireland: The Senior Case Workers Experience
3.2 Aims and Objectives 22
3.3 Overview of Study Design 22
3.4 Sampling and Recruitment 22
3.5 Data Collection 23
3.5.1 Interview Guide 23
3.6 Data Analysis 23
3.7 Ethical Considerations 24
Chapter 4 25Findings Part 1: Elder Abuse, A Unique Phenomenon
4.1 Introduction 25
4.1.1 Profile of the Participants 25
4.2 The Multifaceted Nature of Elder Abuse 25
4.2.1 The Types of Elder Abuse 26
4.2.2 Balancing Self-determination and Risk 27
4.2.3 Ethical Concerns 29
4.2.4 Family Conflict 30
4.2.5 Establishing Trust and Rapport 31
4.3 Summary 31
Chapter 5 33Findings Part 2: Protecting Older People
5.1 Introduction 33
5.2 Case Management and Interventions 33
5.2.1 Responding to Referrals 33
5.2.2 Establishing Protection and Care Plans 34
5.2.3 Case Conferences and Family Meetings 35
5.2.4 Counselling and Support 36
5.2.5 Maintaining Client Relationships 37
5.2.6 Evaluating Case Outcomes 38
5.3 Interagency Working 39
5.3.1 Interagency Referrals 39
5.3.2 Interagency Communication 41
5.3.3 Negotiating Boundaries and Approaches 42
5.4 Experiencing the Role 43
5.4.1 The Lone Worker 43
5.4.2 Managing Caseload and Time 45
5.5 Summary 46
Managing Elder Abuse in Ireland: The Senior Case Workers Experience
Chapter 6 48Findings Part 3: Developing Service Capacity
6.1 Introduction 48
6.2 Supporting the Senior Case Worker 48
6.2.1 Service Structures and Supervision 49
6.2.2 Resource Development 50
6.2.3 Professional Development and Training 52
6.3 Authority to Act 54
6.3.1 Protective Legislation and Policy 54
6.3.2 Statutory Powers for the Role 55
6.4 Standardised Practices and Protocols 56
6.4.1 Current Practice and Procedures 56
6.4.2 Uniform Risk Assessment 58
6.5 Summary 58
Chapter 7 60Discussion
7.1 Introduction 60
7.2 The Complexity of Elder Abuse in Context 61
7.2.1 Sources of Vulnerability 61
7.3 The Practice of Protecting Older People 62
7.3.1 Assessment and Intervention 63
7.3.2 Interagency Working 64
7.3.3 Client Relationship Management 65
7.4 Challenges to Managing Elder Abuse 66
7.4.1 Structural Barriers and Limitations 66
7.4.2 Effective Interagency Communication 67
7.4.3 Balancing Self-determination with Risk 68
7.5 Augmenting the Protection of Older People 69
7.5.1 Developing Resources 69
7.5.2 Standardising Practice 70
7.5.3 Legislative and Statutory Implementation 71
7.6 Limitations 71
Chapter 8 72Conclusion and Recommendations
8.1 Conclusion 72
8.2 Recommendations 72
Managing Elder Abuse in Ireland: The Senior Case Workers Experience i
Relative to other countries, public and professional awareness of elder abuse and policy responses to elder abuse have occurred only recently in Ireland. Nevertheless, since the publication of Protecting Our Future Report in 2002, significant progress has been made in offering a national response to the problem of elder abuse. A key response was the introduction of a dedicated elder abuse service by the Health Service Executive (HSE) in 2007. This included the development of an intervention service for the management of cases of elder abuse delivered by senior case workers for the protection of older people. The senior case workers investigate allegations of elder abuse and work with older people, their families and carers to resolve alleged cases of abuse within the framework of existing policy and legislation.
A review of the literature on systems and strategies for responding to elder abuse points to a vast array of interventions but little guidance as to what might be the most effective approach to helping older people who have been abused or are being abused. Legislation, policy and models of service provision vary widely internationally, and while it is possible to compare various elements of these approaches and to explore potential benefits and limitations, research reporting the efficacy of the responses is limited and it is therefore difficult to determine the merits of certain approaches over others. Likewise the evidence base to support any specific process of intervening is sparse.
While increasing numbers of innovative interventions are being piloted and evaluated, most of the studies published thus far have methodological limitations. Efforts to assess the effectiveness of various projects and systems have also been hindered by a lack of common definitions, theoretical explanations and agreement on desired outcomes.
The literature indicates that the management of elder abuse often involves difficult cases with many ethical challenges and complex dynamics involving the older person, the perpetrator, the practitioner and the service provider. Through a qualitative descriptive research design, this study explored the complexity and challenges of the processes involved in managing cases of elder abuse from the perspective of 18 Irish senior case workers. The aim of the study was to explore the
experience of managing cases of elder abuse from the perspective of senior case workers (SCWs).
A qualitative descriptive research design was adopted using one-to-one semi-structured interviews with senior case workers with responsibility for managing cases of elder abuse. The approach was aimed at permitting a fuller understanding of their experiences in managing cases of elder abuse in the community. Interviews were semi-structured and conducted according to a prepared topic guide to ensure all areas of interest were addressed in each interview. The interview data were transcribed verbatim and subjected to a four-phase analytic process resulting in a thematic structure which reflected the combined deductive and inductive analytic approach.
The study findings highlighted the interlocking forms of abuse encountered by senior case workers and the fluid boundaries between the various forms of abuse. This meant that elder abuse was experienced as a complex phenomenon and therefore difficult to recognise, detect and manage. The senior case workers recognised the particularities of elder abuse cases, which each presented their own unique challenges, issues and dilemmas for social work practice. These particularities included the challenge of reconciling the autonomy and self-determination of their clients with issues of capacity, risk and vulnerability. Additionally, they described the necessity to manage cases of family conflict and entrenched patterns of familial behaviour. The management of this unique phenomenon was understood by the study participants to be highly demanding, in terms of assessing client capacity, making ethical judgements and using interpersonal skills.
Senior case workers provided accounts of case management, from the initial referral to the final case evaluation, showing how the multifaceted nature of elder abuse and its unique complexities and challenges determined the day-to-day practicalities and functions involved in case management and the provision of protective interventions. They spoke about the critical importance of effective interagency relationships and highlighted some of the challenges that they experienced in establishing and maintaining these relationships. The negotiation of role boundaries and responsibilities and the need to reconcile medical and social work discourses concerning best practice were described as potential sources of inter-disciplinary tension. The senior case
Managing Elder Abuse in Ireland: The Senior Case Workers Experienceii
workers pointed to the role of awareness-raising and training as a way to address this challenge. They provided evaluative data concerning the structural and resource contexts in which they operated, pointing to the need to balance resources and case management, which has implications for the delivery of services to those deemed to be at low risk or living in isolated rural locations.
The senior case workers offered their perspectives on the development of protective services, with reference to the capacity of the senior case worker service and the policy and legal framework in which the service is located. Many advocated a team-based approach to the protection of vulnerable adults and the management of cases of elder abuse. They perceived limited resources, inadequate training and a lack of clinical supervision as factors impacting on their service capacity. These structural limitations were described by the senior case workers as contributing to their sense of working on their own and disadvantaging older people living in isolated areas.
The senior case workers identified a need for increased protective legislation for older people and greater statutory powers for the role of the senior case worker. They also spoke of the need for better regulation of solicitors and care professionals and greater statutory authority for their own role in protecting older people from abuse. The senior case workers gave their perspectives on current practice and procedures, identifying a need for standardised procedures, greater consistency across the service regarding best-practice guidelines, procedures for case referral and documentation, and the maintenance of case statistics.
The findings of this study make an important contribution to understanding the complexity and challenges in managing cases of elder abuse in Ireland by revealing the nuanced and multifaceted experiences of 18 Irish senior case workers responsible for managing cases of elder abuse. These experiences are not unique to the Irish context and are reflected in published work on the management of elder abuse in other countries.
The senior case workers reports of their practice in light of the challenges and dilemmas faced by them in managing cases of elder abuse suggest a number of recommendations, which are offered within the limitations of this study. Recommendations for the practice of assessing risk and preventing elder abuse
include the need to consider targeted interventions to promote older peoples self-esteem and enhance their own psychological resources, to continue to examine the social networks of older people as part of risk assessment, and to consider efforts to secure a supportive social network for older people as part of elder abuse case management.
Among recommendations for case management approaches include the need to promote a multi-disciplinary approach and interagency working and to consider ways to formalise existing inter-professional communications and effective interagency and multi-disciplinary working. It is recommended that senior case workers access to and use of care services, which form part of their intervention response in managing cases of elder abuse, be monitored. It is also recommended that caution be applied in drawing on a single case management model and that flexibility in the use of models for managing cases of elder abuse should be applied, so that a chosen model is capable of addressing the complexity that inheres in individual cases of elder abuse.
Recommendations in relation to supporting senior case workers in their role include the need to evaluate current policy guidelines for the SCW role, with the aim of ensuring that the SCW role is supported by clear guidelines that give direction, but also take into account the need for flexibility and the retention of existing informal procedures that are effective in helping them in their practice. It is also recommended that resources to support SCWs case management be further explored along with issues of clinical supervision and peer support for SCWs in their role and that the training needs of SCWs be reviewed on a regular basis. Any increase in the statutory power and authority for the role of the senior case worker or other proposed legislative changes need to be tempered with a need to respect the older persons right to self-determination.
Managing Elder Abuse in Ireland: The Senior Case Workers Experience 1
Chapter 1 Introduction
1.1 BackgroundSince the 1970s, elder abuse has become increasingly recognised and accepted as a global problem. As the population of older people continues to grow worldwide, many countries have begun to take measures to respond to and address this societal issue. In Ireland, public awareness and professional acknowledgment of elder abuse occurred relatively recently. However, significant progress has been made in offering a national response to the problem of elder abuse, with the introduction of a dedicated elder abuse service by the Health Service Executive (HSE) in 2007. This response included the development of an intervention service for the management of cases of elder abuse delivered by senior case workers. The senior case workers investigate allegations of elder abuse and work with older people, their families and carers to resolve alleged cases of abuse within the framework of existing policy and legislation.
Despite these developments there is still a dearth of high quality research on elder abuse both in Ireland and internationally. Elder abuse is a complex and sensitive issue, which to date lacks a sound theoretical base (Penhale 2006). A lack of agreement concerning definitions and causes makes it a challenging area to research. Accordingly, there is still little consensus on best practice in response to elder abuse. The aim of this study, therefore, was to explore the experience of managing cases of elder abuse from the perspective of senior case workers. The objectives of the study were to:
Explore senior case workers experiences in managing cases of elder abuse
Examine current practices adopted by the senior case workers
Examine the challenges and dilemmas faced by senior case workers in managing cases of elder abuse and how these are overcome
Identify good practice in the management of elder abuse cases, as perceived by the senior case workers
Ascertain priorities for future service development and provision for elder abuse, as perceived by the senior case workers.
1.2 Report Structure
This report is presented in seven chapters. Chapter 1 presents the background and rationale for the study, and offers an overview of developments in response to elder abuse in Ireland and a range of other countries. This provides a global and national context for the study. Chapter 2 provides a review of the literature on the management of elder abuse cases in practice, including modes of intervention and the availability of evidence for their effectiveness. Chapter 3 provides a description of the research design and methods of participant recruitment, data collection and analysis. This study employed a qualitative research design in order to ascertain the perspective of senior case workers on managing cases of elder abuse. This ensured that the research findings were grounded in the experiential knowledge of the senior case workers. The findings which emerged from a thematic analysis of the interview data are presented in Chapters 4, 5 and 6. These chapters are structured according to the major themes which emerged from the data analysis through a combined process of deductive and inductive reasoning. This ensured that the analysis and the findings were informed by the experiences and perspectives of the senior case workers.
Existing national and international knowledge in the areas of the protection of older people and the management of elder abuse provide a context for the interpretation of the study findings, which are presented in Chapter 7. Furthermore, this discussion identifies the contribution that this study makes to existing literature in the relevant fields. Finally, the conclusion of the report indicates the key findings of this study in relation to the core study objectives. These objectives are concerned with the current practices and challenges of senior case workers in their management of elder abuse as well as identifying good practice and ascertaining priorities for future service development.
1.3 International Developments in Response to Elder Abuse Countries around the world are at varying stages in the development of national and local responses to protect older people from abuse (WHO 2002). Some countries have advanced policies, laws, and services to address the problem, while certain others have made little if any progress in acknowledging the existence of elder abuse
Managing Elder Abuse in Ireland: The Senior Case Workers Experience2
Chapter 1 Introduction
at all. The United States (US) has long been considered at the forefront of research and practice in elder abuse (World Health Organisation (WHO) 2002, Perel-Levin 2008). Adult Protective Services (APS) are at the core of the US response to elder abuse and play a pivotal role in investigating and responding to alleged cases of mistreatment (Bonnie and Wallace 2003).
The majority of states in the US employ dedicated adult protection workers to work with adults of any age who are considered vulnerable to abuse or neglect (Stiegel and Klem 2007). Mandatory reporting requirements are also a prominent feature of this protection-oriented service model (Bonnie and Wallace 2003, Desmarais and Reeves 2007, Brownell 2010). However, there are some exceptions to a policy of compulsory reporting; for example in New York authorities have resisted the introduction of mandatory reporting laws, based on concerns about the civil liberties of older adults. They have focused their attention on education and prevention rather than protection (Brownell 2010). Specialist multi-disciplinary elder abuse teams are also increasingly involved in the response to elder abuse in some areas, providing education, and assessment and assistance in dealing with complex cases (Dyer et al. 2005, Nerenberg 2006). Many states in the US have long standing formalised protocols for referrals and inter-disciplinary interaction. Alongside protective services, the involvement of criminal justice in the area of elder abuse has grown. Elder abuse is increasingly being criminalised in state legislation and rising numbers of cases are being prosecuted annually.
Protective service models have been introduced in Canada and in Norway; the latter countrys government funded a pilot project establishing Elder Protective Services in Oslo. This pilot project has since been adopted by other municipalities in Norway. Where elder protective services have been developed, there are specialist workers in place who act as the focal point for all cases relating to the abuse of older people. However, although services were influenced by the systems developed in the US, there are important cultural, ideological and organisational differences in their approach (Juklestad 2004). In Norway, there tends to be more emphasis on the principles of client autonomy, advocacy and rights (Johns and Juklestad 1995). There is no national policy and no specific legislation to deal with elder abuse in Norway. However, the Norwegian
government has made education and awareness-raising key priorities for the prevention of elder abuse and has funded a resource centre as well as a telephone helpline to assist victims of abuse.
The UK addresses elder abuse within the context of vulnerable adults and adult protection is usually managed within mainstream adult social care services rather than dedicated services. Elder abuse is addressed primarily through guidance, policy documents and codes of practice, emphasising appropriate procedures to follow in cases of abuse of vulnerable adults of any age. Reporting of suspected abuse is not mandatory in the UK but legislation and policies are in place to protect those who do disclose suspicions of abuse. The emphasis within the UK model is on achieving an appropriate balance between autonomy and protection. National guidelines are presented in the document No Secrets, which recommends the establishment of multi-disciplinary adult protection committees at local level to facilitate interagency collaboration and partnership working (Department of Health 2000). There has also been an emphasis on regulation and inspection within health and social care services. A number of new initiatives have been proposed by the UK Government, including putting adult protection committees on a statutory footing and increasing emphasis on the law around safeguarding adults (Department of Health 2010). However, in contrast to the US, and similar to other European countries, the UK response is focused upon providing necessary services to end abuse and restore relationships, rather than punishing perpetrators (Filinson 2006).
Australia has no national federal policy on elder abuse and most states do not have dedicated or specialist services to identify and assist victims of elder abuse (Lowndes et al. 2009). However, individual states and territories have begun to develop strategies to respond. For example, the Australia Capital Territories, South Australia and Queensland have funded specialist information and education services to provide telephone assistance and referral support in dealing with suspected cases of abuse. In Victoria, Senior Rights Victoria (SRV) was established in 2008 to safeguard the rights of, dignity and independence of older people. SRV acts as a point of contact for older people, concerned family or friends, professionals or members of the general public and provides legal services, advocacy and support, and referrals to health and social services in the community
Managing Elder Abuse in Ireland: The Senior Case Workers Experience 3
Chapter 1 Introduction
(Victorian Government Department of Human Service 2009). In other Australian states, cases of elder abuse tend to be dealt with by existing services such as Aged Care Assessment Teams.
Elder abuse has been explored from many different perspectives and there is ongoing debate as to whether it is primarily an issue of human rights, domestic violence, public health, adult protection, criminal justice or empowerment. These overall paradigms can shape responses to elder abuse, and influence the types of laws enacted in a country, the policies developed and the services made available. The approaches adopted to deal with abuse are often dependent upon the discipline or theoretical background of those responsible for responding to the problem within each country. Social work practitioners and advocates, for example, tend to welcome an empowerment model. This model focuses on restoring power to the victims by encouraging them to exercise their right to self-determination, and ensuring that interventions reflect their preferences (Nerenberg 2008). However, the empowerment model is at odds with the core principles of other systems such as criminal justice which concentrate on protecting the public and holding offenders accountable rather than on the empowerment and support of the victim.
1.4 The Irish Response to Elder AbuseRecognition of elder abuse within the professional health and social care realm in Ireland began with the publication in 1990 of two case reports in Irish medical and social work journals. In 1996 a preliminary briefing on elder abuse was prepared by the National Council for the Elderly and submitted to the Minister for Health. The National Council on Ageing and Older People subsequently commissioned an exploratory study on elder abuse in an Irish context following media reports of a number of particularly distressing cases. The resulting report entitled Abuse, neglect and mistreatment of older people: An exploratory study, published in 1998, explored the issue of elder abuse in the light of Irish and international literature and the views of service providers. The report made recommendations on the mechanisms needed to effectively address the problem of elder abuse in terms of policy and infrastructure (OLoughlin and Duggan 1998).
Out of the recommendations from this report, a Working Group on Elder Abuse (WGEA) was established to advise the Irish government on what was required to effectively and sensitively address the issue. The working group, made up of representatives from relevant agencies in the voluntary, public and private sectors, established a pilot project in two health board areas to inform future plans and policy development. The pilot programme allowed the working group to test and evaluate how draft procedures and guidelines worked in practice. The group also assessed the effectiveness of a specially designed training programme for health and social care staff. The report of the WGEA, Protecting Our Future, was published in 2002 and set out a framework for the development of policies and procedures to respond to actual or alleged cases of elder abuse. It also set out the infrastructure necessary for the implementation of the proposed policies and procedures (WGEA 2002). Recommendations were made in areas such as policy, staff structure, legislation, impaired capacity, carers, awareness, education and training, financial abuse, advocacy, research, reporting abuse, and implementation and review of the recommendations. At the time of writing, Protecting Our Future remains the seminal document on elder abuse in Ireland.
Following the publication of Protecting Our Future in 2002, the Irish government established an Elder Abuse National Implementation Group (EANIG) to oversee the implementation of the recommendations contained within the report. Established in December 2003, the group was recently disbanded. EANIG was a multi-disciplinary group made up of representatives from a wide range of agencies working with older people. The group had a key role in progressing the development of services to respond to elder abuse and in particular the establishment of the current HSE-dedicated elder abuse structures (NCAOP 2009).
1.4.1 HSE Dedicated Elder Abuse Structures
Significant progress has been made in recent years in Ireland in the development of a national response to the problem of elder abuse. This progress has been primarily driven by the health sector. This has placed considerable emphasis on research, policy development, education and awareness-raising, as well as on the provision of dedicated elder abuse services. In 2007 the HSE established a new specialist service intended to provide a coordinated and holistic approach to elder abuse, based
Managing Elder Abuse in Ireland: The Senior Case Workers Experience4
Chapter 1 Introduction
on a modified version of that proposed in Protecting Our Future in 2002.
A multi-disciplinary National Elder Abuse Steering Group and four Area Elder Abuse Steering Groups were established to oversee the provision of elder abuse services by the HSE as well as the implementation of the recommendations of Protecting Our Future. Four Dedicated Officers for Elder Abuse posts were created in four HSE administrative areas, namely HSE West, HSE South, HSE Dublin Mid-Leinster and HSE Dublin North East. At the time of writing, the position in HSE South was vacant. These dedicated officers have responsibility for the development, implementation and evaluation of the HSE elder abuse services. They deal with the implementation and on-going review of elder abuse policy and contribute to strategic planning, development of services, training, and collation of statistics.
In practice the service is delivered by qualified social workers, known as senior case workers (SCWs), who deal primarily with suspected cases of abuse referred to the HSE, involving people aged 65 and over. Up to 30 senior case workers (SCWs) for the protection of older people are employed in local health offices (HSC 2011). SCWs investigate allegations of elder abuse and work with older people, their families and carers to resolve alleged cases of abuse within the framework of existing policy and legislation. Senior case workers are primarily based within primary community and continuing care services, reporting to the general manager, and collaborating with Dedicated Officers for Elder Abuse, and other relevant stakeholders.
A recent report, entitled Review of the Recommendations of Protecting Our Future: Report of the Working Group on Elder Abuse, published in early 2010, examined the structures established by the HSE in relation to the management of elder abuse and found that significant progress had been made in implementing the recommendations contained within Protecting Our Future, particularly within the health sector (NCAOP 2009). However, a number of issues were highlighted relating to the response provided by this specialist service. These included regional inconsistencies in approach, a lack of interagency cooperation, in particular, a need for senior case workers to be more fully integrated into the wider services for older people and a lack of professional supervision for SCWs in some areas (NCAOP 2009).
Managing Elder Abuse in Ireland: The Senior Case Workers Experience 5
Chapter 2 Managing Elder Abuse in Practice
2.1 IntroductionThis chapter provides a detailed review of literature on the operational processes associated with the procedures and systems adopted nationally and internationally for dealing with cases of elder abuse. The review concerned with the processes of managing cases of elder abuse found an absence of research directed at evidence-based practice. Several descriptive studies were found, with a limited number of quality primary studies on which to base recommendations for practice (Kalaga et al. 2007, Ploeg et al. 2009). The literature suggests a wide variety of approaches for managing cases of elder abuse but overall responses to the problem are generally considered to be inadequate (Nerenberg 2006, Ploeg et al. 2009).
Arrangements for managing cases of elder abuse are likely to vary depending on the nature of the case, the local and national management and organisational structures, and the skills, experience and interests of individual practitioners. Cambridge and Parkes (2004b) identified a number of stages in the process of managing adult protection cases in the UK, which included initial referral or alert, preliminary investigation, planning meetings, investigation by social services or police, case conference and case closure or on-going monitoring. The authors acknowledged that adult protection cases are frequently complex and do not necessarily follow a sequential model. In many cases there may be multiple or parallel investigations and concurrent planning or case conferences as new evidence emerges.
2.2 Aims and Method of Literature ReviewA review of literature was conducted to locate the present study within the context of international published literature on the topic. The purpose of the literature review was to provide background information to inform the development of the research and to establish the current state of knowledge and evidence on the process of managing elder abuse cases in the community and the various intervention strategies employed.
A thorough search was carried out using four electronic databases: CINAHL Plus, Embase, Medline and PsychINFO. The terms elder abuse and elder mistreatment were searched in combination with
keywords such as assessment, best practice, detection, identification, intervention, management and strategy. Only literature published in the English language were searched. Additional references, including relevant articles and grey literature, were also retrieved. This retrieval was informed by the reference lists of the selected papers and from a Google search using a number of the same search terms.
Literature addressing self-neglect or abuse in institutional settings, such as nursing homes, long-term care facilities or hospitals, was considered outside the scope of this review and were excluded accordingly. These types of abuse and neglect are likely to have distinct and different causes and outcomes and are considered better addressed separately (National Research Council 2003). The majority of the literature originated in the United States, Canada and the United Kingdom. However, a small number of papers from other countries such as Australia, Ireland and Israel were also included.
2.3 Detection and Referral Detection is a critical first step in the effective management of the problem of elder abuse. Halphen et al. (2009) assert that the most beneficial intervention is reporting suspected cases of elder abuse to appropriate agencies or services. Interventions by designated authorities to manage the problem and prevent future incidents of abuse cannot occur without identification and referral. Although awareness of elder abuse has increased in recent years, there is a general consensus that detection and reporting rates continue to be low, and known cases are just the tip of the iceberg (Baker and Heitkemper 2005, Perel-Levin 2008, Cooper et al. 2009).
Self-referral is uncommon in circumstances of elder abuse. This is attributed to a lack of physical means or mental capacity as well as feelings of shame and fear (Wolfe 2003, McGarry and Simpson 2011). An onus is therefore placed on agencies in contact with older people to be alert to any signs of mistreatment and to report concerns to appropriate authorities (Ross 2007). Research indicates that recognition of cases of elder abuse may be hindered by barriers to detection and identification. These barriers include a lack of awareness as well as difficulties distinguishing between age-associated disease and mistreatment (OLoughlin and Duggan 1998, Penhale
Managing Elder Abuse in Ireland: The Senior Case Workers Experience6
Chapter 2 Managing Elder Abuse in Practice
2006). Furthermore, reporting may be complicated by a lack of knowledge about where to report suspicions (Bonnie and Wallace 2003, Halphen et al. 2009).
Screening tools have been suggested as the means of improving recognition of potential elder abuse cases (Anetzberger 2001). However, although several screening tools have been developed, none has gained widespread use (Bonnie and Wallace 2003, Fulmer et al. 2004, Anetzberger 2004, Perel-Levin 2008). Traditionally a key requirement of the screening process is a cut-off point for deciding whether a case is screened positive or negative. An assessment of the merits of this cut off approach for managing cases of elder abuse has generated some debate. This debate has focused on the complexities of elder abuse and the necessity of employing a considerable degree of clinical judgement in the management of cases. Researchers have argued that the necessity for clinical judgement in elder abuse cases negates the use of statistical measures of risk (Bonnie and Wallace 2003). Elder abuse is a complex phenomenon with multiple causes and outcomes and there are no standard criteria for diagnosis (Fulmer et al. 2004). However, screening tools are believed to heighten professional awareness and guide users through a systematic process of observation and inquiry which ensures that potential cases of elder abuse are not missed (Anetzberger 2001, 2004). Some screening tools may therefore be useful for guiding professionals who have suspicions of abuse and thereby facilitate referral for further assessment.
Education, training, and support for professionals who may be likely to encounter elder abuse and neglect are considered a fundamental strategy for the increased detection of elder abuse (Lachs and Pillemer 2004, Perel-Levin 2008). Lack of knowledge has been shown to influence reporting rates for elder abuse amongst a range of health and social care professionals (McCreadie et al. 1998, McCreadie et al. 2000, Oswald et al. 2004). Killick and Taylor (2009) reported the results of a systematic review of professional decision-making and found that training and knowledge were shown to impact on the level of abuse identification.
Specific guidelines and protocols for identifying and responding to elder abuse are now considered essential in almost all health and social service professional organisations (Fulmer et al. 2004). Protocols may be
useful to ensure responses to suspected cases of elder abuse are consistent by highlighting key steps in the process (OLoughlin and Duggan 1998, Lachs and Pillemer 2004, Saliga et al. 2004). These may include identifying indicators of abuse, reporting structures for suspected cases, comprehensive written documentation and procedures for referral (Anetzberger 2001, McGarry and Simpson 2011). They may be especially helpful in clarifying roles, responsibilities and accountability when there are multiple services and agencies involved in handling elder abuse cases (Anetzberger 2001). Finally, protocols may reinforce the responsibility on professionals to act when they suspect abuse has, or is likely, to take place (Wolfe 2003).
Consistency in policy and procedure is discussed in the relevant literature in terms of the benefits of standardised protocols for managing elder abuse. However, this literature also indicates concerns that structured protocols or guidelines may be overly simplistic to deal with the complexity surrounding many cases of elder abuse (OLoughlin and Duggan 1998, Lachs and Pillemer 2004). Attempts have been made to overcome this problem. For example, The Ontario Association of Professional Social Workers outlined eight different decision trees to provide general reference points and to initiate decision-making processes. These models stress that no standard formula can deal with the complex issue of elder abuse (OLoughlin and Duggan 1998).
In some countries, certain individuals, including health care and law enforcement professionals, are ethically and legally obliged to report suspicions of elder abuse or neglect (Cooper et al. 2009, Lowndes et al. 2009). Mandatory reporting laws typically contain definitions of abuse, specify who must report, and to whom reports should be made. Furthermore, they often incorporate penalties for failure to report concerns, including fines, or in extreme cases, loss of licensure (Fulmer et al. 2004, Nerenberg 2006). However, mandatory reporting remains a controversial issue and has never been subjected to rigorous evaluation (Bonnie and Wallace 2003, Perel-Levin 2008). According to Peri et al. (2008) research indicates that whether people report abuse, or not, has more to do with organisational, professional, cultural and ethical issues than whether there is a legal requirement to do so. The provision of legal protection for those who do disclose suspicions of abuse in good faith to an
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appropriate authority is a widely employed strategy to encourage reporting.
There is little information in the literature on the practical process of referral and investigation into cases of elder abuse. Where mandatory reporting laws exist, there are usually specific designated recipients of reports. In the United States and Canada, this is usually the responsibility of Adult Protection Services (APS). Dayton (2005) describes the process of referral and steps in the investigation by APS in Ohio: The first contact between the person who refers the case and the APS intake officer should include discussion about the physical and mental capacity of the older individual, their ability to care for and protect themselves, and whether there are indications of abuse or neglect, based on definitions in local legislation or policy documents (Dayton 2005).
If elder abuse is suspected, one of the first steps must be to determine the urgency of the situation by assessing the risk to the older persons safety (Cambridge and Parkes 2004b, Donovan and Regehr 2010). Cambridge and Parkes (2004b) report that the key skills considered necessary at this stage of an alleged adult protection case centred on keeping an open mind, the ability to listen and not over-react, having good communication skills, for example communicating with people with dementia, and having basic assessment abilities.
2.4 Investigation and AssessmentLocal laws or policy documents usually set out which agency or organisation is responsible for investigating suspected cases of elder abuse. In Scotland, for example, the Adult Support and Protection (Scotland) Act 2007 gives statutory responsibility to local agencies to investigate any risk of harm or abuse to older adults living in care homes or in the community and enhances powers to investigate allegations of mistreatment (Heath and Phair 2007). In the rest of the UK, guidance issued by the Department of Health and the Welsh National Assembly in 2000 under Section 7 of the Local Authority and Social Services Act 1970 gave local authorities, known as Councils with Social Services Responsibilities (CSSRs), the lead role in responding to adult protection and elder abuse. In the US, APS are usually the designated authority with responsibility to investigate and intervene in suspected elder abuse cases (Bonnie and Wallace 2003, Halphen et al. 2009). In Australia, assessments are
usually carried out by an Aged Care Assessment Team or an Aged Care Service (Kurrle 1993).
Investigations undertaken by Adult Protective Services (APS) in the US typically include a face-to-face home visit, an assessment of capacity and functional ability, and a needs assessment for medical, social, legal or financial services (Nerenberg 2006). Under Ohio State law an investigation by an APS social worker must begin within 3 days, or 24 hours in life-threatening cases (Dayton 2005). If the case is a re-referral, the case is assigned, where possible, to the social worker previously involved. A home visit is made, as a requirement of the law, and written notice is given of the purpose of the investigation, explaining that a call has been received by APS, indicating that the individual may have been abused, neglected, or exploited, or may be unable to take care of his or her own needs. The source of the referral remains confidential. The home interview is conducted in private and a critical issue is the assessment of mental status and capacity to make decisions. Investigations are likely to involve continued contact with the person who made the referral (Dayton 2005). They may also include interviews with the alleged perpetrator. Additionally, consultations with social security staff, mental health professionals, primary care physicians, home health staff, family, friends, neighbours, financial institutions and the police may be undertaken to obtain a comprehensive and accurate understanding of the situation (Dyer et al. 2005).
Fulmer et al. (2003) examined transcripts of discussions by a Neglect Assessment Team in a medical centre in New York relating to four practice cases and nineteen real cases. They found that much consideration was given to contextual information relating to the older person and their caregivers when assessing for potential neglect. This included information on the health and capacity of the older person and the caregiver, their social and economic circumstances, and the reliability of information from sources concerned. Similarly Lithwick et al. (2000) found that practitioners in community services in Canada were influenced by contextual factors such as cognitive impairment, intent, poor relationships and mutual abuse in cases where they struggled to decide whether behaviours constituted mistreatment or not.
Participants in a UK study reported by Cambridge and Parkes (2004b) advocated the necessity of a designated individual to coordinate or lead the investigation.
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According to Pratt et al. (1983) a sensitive personal approach to the older person and their family is crucial at the preliminary stage of an investigation, as it sets the tone for future interactions and may affect the way all subsequent interventions are perceived. Cambridge and Parkes (2004b) also identified communication, listening and negotiation skills as key abilities at this juncture. Accurate recording and reporting, good risk assessment capacity, ability to liaise with other agencies and services, ability to assess capacity to consent, and analytical skills were also identified as important attributes for professionals at this stage (Cambridge and Parkes 2004b). A good knowledge of policies, procedures, responsibilities and legislation, and the ability to assess the support needs of individuals are also considered critical (Cambridge and Parkes 2004b).
2.5 Intervention Strategies and Services ProvisionThe identification and reporting of elder abuse creates an imperative for the development of effective interventions and strategies to manage identified cases and prevent further mistreatment (Perel-Levin 2008). Intervention strategies for elder abuse involve the application of available services, laws and clinical procedures to treat the consequences of abuse or to prevent its occurrence or recurrence (Anetzberger et al. 2005). A wide range of practical and therapeutic interventions have been proposed, which aim to protect the welfare of individuals who have experienced abuse or are at risk of abuse. These responses to abuse are typically provided by health and social services. Interventions are delivered at a point of crisis, such as telephone help lines and emergency shelters, as well as longer-term interventions, including respite care, counselling and social support (Kalaga et al. 2007, Podnieks 2008). Intervention techniques are still in quite early stages of development and there is little evidence to support their effectiveness (Penhale 2006, Ploeg et al. 2009). Consequently, there is limited understanding about the interventions which are likely to be most effective in combating elder abuse (WHO 2011).
2.5.1 Case Management
Case management is one method of delivering a holistic response tailored to the specific needs of those involved in cases of elder abuse. This approach has been identified and recognised by many as an effective strategy to
improve quality of care and outcomes for older people (Luu and Liang 2005). Case management may be provided by public or private agencies on an on-going basis (Dayton 2005). Case managers, usually nurses or social workers, are responsible for performing comprehensive assessments as well as developing care plans and coordinating the delivery of health and social care services (Luu and Liang 2005). The goal of case management is generally to maintain the highest level of independence and autonomy possible (Nerenberg 2008). Case managers act as advocates, educators and facilitators (Luu and Liang 2005). While there are several models of case management, they generally all share a common purpose, linking clients with essential resources and services (Hepworth et al. 2010).
Some early work on elder abuse highlighted the importance of coordination of referrals to prevent older people becoming lost within a complex system of agencies and professionals (Pratt et al. 1983). Case management can prevent fragmentation in the provision of services and ensure no information is lost between disjointed services and agencies (Luu and Liang 2005, Kalaga et al. 2007). Case managers closely monitor the progress of clients, respond to problems or emergencies, and conduct routine re-assessments to evaluate the effectiveness of the care plan and detect any changes in need (Nerenberg 2006). This is especially important as the needs of older people are often dictated by functional ability which may fluctuate over time (Nerenberg 2008). The case management approach has been implemented in Ireland in recent years through the SCWs who investigate, respond to and manage suspected cases of elder abuse (HSE 2009).
Monitoring has been identified as one of the core tasks of case management and was one of the most commonly reported interventions provided to victims of elder abuse in Ireland in 2010 (HSE 2011). Shibusawa et al. (2005) described a case study illustrating the way on-going monitoring is employed as an intervention strategy by social workers in Japan where mistreatment is suspected. In this case periodic home visits were utilised to give social workers the opportunity to continue to observe the older persons condition and circumstances, and to establish an on-going trust relationship with the client and their family and caregivers.
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Counselling was the third most commonly-recorded intervention for victims of elder mistreatment in Ireland in 2010 (HSE 2011). Low self-esteem and stress can place many older people at risk of abuse or neglect and can reduce their ability to cope with abusive situations (Podnieks 2006). Many victims of elder abuse develop feelings of fear, guilt, shame, isolation and anger. Counselling may be an important and effective therapeutic intervention to help older people who have experienced abuse to alleviate traumatic stress, understand their feelings, regain a sense of independence, emotional strength and self-esteem, and to prevent recurrence of abuse or mistreatment (McKenzie 1999, Podnieks 1999, Nerenberg 2006, Kalaga et al. 2007). Counselling is considered one of the most highly valued services available to victims of elder abuse (Nerenberg 2008). In a qualitative study reported by Hightower et al. (2006), involving 64 women over 50 years of age in Canada, women spoke of the emotional abuse they suffered, including being put down and ridiculed. All of the women in the study spoke of a need for emotional support, someone trustworthy to listen to them, to believe them and keep their confidence, as well as offer practical advice.
2.5.4 Support Groups
Social support has been identified as a potentially protective factor against elder mistreatment. Research has found higher levels of social support to be independently associated with a lower risk of self-reported mistreatment (Naughton et al. 2010), while victims of abuse with less social support are thought to have higher levels of psychological distress (Fulmer et al. 2005, Dong and Simon 2008). Older adults who experience abuse may be more socially isolated and have fewer social contacts than non-abused older people (Podnieks 2006). Community-based support groups have therefore been proposed as effective interventions for both perpetrators and victims of elder abuse (Podnieks 1999, Hightower et al. 2006, Dong and Simon 2008). Pritchard (2007) describes the organisation Beyond Existence in the UK, which, following a pilot study, had successfully secured funding to offer support groups for older people experiencing and recovering from abuse. Support groups act as a source of affirmation, information and education, creating an empowering environment (Podnieks 1999).
Support groups have been used with women who were victims of domestic violence and are purported to have many psycho-social benefits such as the development of mutual support relationships with peers, moving past guilt, enhancing self-esteem, and learning problem-solving and coping strategies (Podnieks 1999). In a qualitative study of older womens experiences of domestic violence, Schaffer (1999) found that older women valued having peer support and other women of similar age to talk to about the abuse. The assumption behind support groups is that people who have had similar experiences are better equipped to understand and empathise with people experiencing or recovering from abuse (Nerenberg 2008). Traditionally the term support group referred to informal gatherings of people who were experiencing similar life events and were led by lay persons. However, more recently the term is also applied to more formal circumstances where professionals introduce therapeutic and educational methods within a group setting (Nerenberg 2008).
The literature reveals that endorsements for the benefits of support groups are based primarily on anecdotal evidence (Brownell and Heiser 2006). One of the few empirical evaluations produced findings that may question the efficacy of support groups as an intervention. Brownell and Heiser (2006) carried out a pilot study with 16 women, 9 of whom received a weekly 2 hour psycho-educational support group intervention for 8 weeks, while 6 were randomly assigned to a control group. The support group was facilitated by a graduate social work student and a retired professor, and covered a range of topics including: domestic violence, abuse neglect, family dynamics, self-esteem, depression, anxiety and stress, strategies for change, and services and resources available. Interviews were conducted two months before and after the intervention and no significant differences were found between or within groups on outcome measures including depression, guilt and self-esteem. However the authors noted that all but one of the participants reported that the group was helpful in increasing their self-esteem and well-being. Due to the small sample size and the limited information available about the measures employed, these results were far from conclusive (Ploeg et al. 2009). More information is still needed to determine the effectiveness of this type of intervention and how it may benefit victims of elder abuse.
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Support groups for perpetrators of elder abuse have also been proposed based on the principles of groups involving men who have committed domestic abuse, although few programmes are in place (Podnieks 1999). The group Lifespan in Rochester in New York runs one of the first groups for perpetrators of elder abuse. Entitled Stop Elder Abuse and Mistreatment (SEAM), the intervention entails a 16-week programme intended to change attitudes and behaviour, and prevent further mistreatment by raising awareness of the impact of abusive actions on victims (Nerenberg 2006). Programmes in San Francisco and Los Angeles have also experimented with small groups targeting perpetrators and using cognitive behavioural techniques to alter violent behaviour (Bonnie and Wallace 2003). No data was identified in the course of this literature review that evaluated the effectiveness of such programmes but the few methodologically-sound evaluations of programmes for abusive men in domestic violence cases are not especially encouraging. Dropout rates from programmes, even when court-mandated, are quite high and differences in repeat offending between those who attend interventions tend to be small and generally not significant (Wolfe 2003).
2.5.5 Interventions for Caregivers
Early research on elder abuse was frequently based on the premise that the stress or burden of caring for a dependent older person, or the lack of care-giving experience, knowledge and resources could lead to abuse or neglect (Reingold 2006, Nerenberg 2008). On this basis, training, education and support programmes are seen as vital aspects of prevention and management of elder abuse within a care-giving relationship (Wolfe 2003, Ross 2007). Self-assessment tools have been designed to help caregivers assess their own risk of becoming abusive (Nerenberg 2008). Caregiver support groups are intended to reduce isolation and provide emotional support and guidance in how to meet the demands of care giving and how to handle difficult behaviour which may increase tension and give rise to stress (Nerenberg 2008).
The extent to which training interventions with caregivers may reduce the risk of abuse or neglect is still a matter of debate (Nerenberg 2008). One study by Scogin et al. (1989), for example, found no statistical differences in terms of anger, self-esteem, caregiver burden or general
mental health between caregivers who received 8 weekly training sessions and those caregivers who had no such training. However, no information is provided in the study to ascertain whether there were differences between groups at baseline data collection (Ploeg et al. 2009). Other studies suggest that interventions targeted at abusive caregivers may help prevent re-offending (Nahmiash and Reis 2000, Reay and Browne 2002). Nahmiash and Reis (2000) found that strategies focused on the abuser, such as individual and family counselling, were the second most successful interventions after medical and nursing care provision. This approach to prevention and management of elder abuse is controversial. Recent research has shown correlations between abuse and higher care burden (Cooper et al. 2009). However, some researchers question the evidence linking elder abuse and caregiving stress (Lachs and Pillemer 2004). More research is needed to evaluate not only the efficacy of interventions with caregivers but also the role of care giving as a risk or causal factor as such interventions may have preventive potential in only a limited subset of cases (Pillemer et al. 2007).
2.5.6 Home Support Services and Respite Care
The most common intervention strategy employed by social workers who encounter abuse and neglect in family care giving situations in Japan is the arrangement of formal care giving services (Shibusawa et al. 2005). In Ireland in 2010 one of the most common interventions recorded by senior case workers was the provision of home support services, offered to approximately 20 percent of clients (HSE 2011). In a qualitative evaluation of 473 interventions used in 83 cases of elder mistreatment perpetrated by caregivers in Canada, a multi-disciplinary team rated general medical, nursing and rehabilitation strategies as the most successful in terms of stopping or reducing abuse or solving the identified problem (Nahmiash and Reis 2000). Professionals working with elder abuse victims have suggested that many abusive situations could be prevented if carers had more access to resources (Pritchard 2000). Services also suggested to relieve the burden of care-giving and prevent elder abuse include house-keeping, meal preparation or delivery, transportation and friendly visitors (Pillemer et al. 2007). Provision of support services can help to promote independence for those living in the community, reduce
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social isolation and take pressure off informal caregivers (Nerenberg 2008). Service providers also note that offering support services is a credible means to establish a positive trusting relationship with clients who may be unwilling to take action against the perpetrator of abuse (Nerenberg 2008).
Respite care services can provide relief to caregivers for anything from a few hours up to extended periods. These services are delivered either through professional or volunteer carers, in the home of an older person, at day centres or in institutional settings (Nerenberg 2006). A three-year follow up study of victims of elder abuse in an area-based aged care service in Australia found that, despite the provision of community services and respite care, a significant proportion of older people remained in abusive situations. However, according to the author these community services were valued as much for personal contact as for the provision of practical assistance (Kurrle 1993).
2.5.7 Emergency Shelters, Refuges, Safe Houses and Long Term Care
Emergency shelters and refuges have been a central component in the response to domestic violence (OLoughlin and Duggan 1998). In some circumstances older people may also require a safe haven to remove them from an unsafe setting to avoid imminent or further abuse. Emergency refuge for older people may take the form of battered womens shelters which have been adapted to meet the needs of older women, nursing home facilities, or shelters specifically designed for victims of elder abuse (Nerenberg 2006). However, domestic abuse services are often ill-equipped to deal with the specific and complex needs of older people, especially those who may be physically frail or lacking mental capacity (Kalaga et al. 2007). Qualitative research indicates that older women often find shelters chaotic places (Hightower et al. 2006). The literature contains few reports of specific elder abuse shelters.
The Weinberg Center in New York provides one example of a long-term shelter dedicated to victims of elder abuse (Reingold 2006). The shelter is accessed via a 24 hour free phone number, providing an initial contact point for crisis intervention. If telephone screening indicates a need for emergency shelter, triage and multi-disciplinary assessments are undertaken by staff from a medical day programme called Elder Serve. These staff members are
specially trained to address the needs of elder abuse victims. A dedicated, comfortable, safe and secure short term stay unit is available for emergency housing and support for older men and women for whom it is unsafe to return to their homes. This shelter is housed within a larger residential complex for older people, known as the Hebrew Home. This allows for the provision of a wide array of services and takes advantage of existing expertise in the care needs of vulnerable older people. Although dedicated to victims of abuse, this short stay unit also houses other short-term older residents because it is considered that integration may be beneficial for previously isolated older people by removing the stigma associated with abuse and fostering social support (Reingold 2006). Similarly, shelters for women experiencing domestic abuse are considered a means of developing support networks (OLoughlin and Duggan 1998, Hightower et al. 2006). Victims of elder abuse may stay in the unit for approximately 30 days, after which arrangements are made either to return home, if safe, with community support services such as counselling and legal advocacy, or to transfer to either sheltered housing or admission to long-term residential care. While short-term removal from the abusive situation may be beneficial in some circumstances, interventions in elder abuse often result in long-term residential care.
The Kerby Rotary House in Calgary, Canada, was one of the first purpose-built shelters for abused older people. This service offers safe and secure shelter to men or women, alongside crisis intervention, support, advocacy and referral (Alberta Elder Abuse Awareness Network 2009). In Scotland, the Dumfriesshire and Stewartry Womens Aid designed one of its shelter specifically for women over the age of 50. This organisation also employs a full-time project worker to provide support, counselling and advice to older women, which continues after they have been resettled (Kalaga et al. 2007). The Westgate Foundation in Cork currently offers the only emergency shelter accommodation in Ireland for older people who have suffered any type of abuse. This facility was established after examining the best international examples and consultation with social workers and health workers throughout the area (Cork Independent 2009). The shelter accepts referrals from GPs, social workers, and a wide range of other agencies.
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2.5.8 Telephone Services
Telephone helplines have been introduced in a number of countries, including France, Belgium and Israel, and have been considered an effective source of information and support for individuals who have been affected by any type of abuse or who may be at risk of abuse (Kalaga et al. 2007, Penhale 2007). These services can provide verbal counsel with the reassurance of confidentiality and anonymity (Kalaga et al. 2007). They may also be helpful for any concerned members of the public or professionals requiring additional information. Elder Abuse Response, run by the charity organisation Action on Elder Abuse, is one example of this type of service. Launched in 1997 following a successful 12-month pilot project in four areas of the UK, this is the only national helpline in the UK or Ireland dedicated to elder abuse (Action on Elder Abuse 2004). It is operated by specially trained staff and volunteers providing free confidential information and advice to members of the public (Action on Elder Abuse 2004). In Ireland, a number of telephone helplines have been introduced. The HSE offers a national information telephone helpline which provides details of HSE staff who can assist older people who are being abused. Also, a confidential senior helpline is offered by a voluntary organisation called Third Age. This service is a telephone listening service for older people and is manned by trained older volunteers.
2.5.9 Daily Money Management (DMM)
Daily money management (DMM), including assistance in paying bills, writing cheques, and making bank deposits or withdrawals is gaining popularity as a potential practical intervention to reduce the risk of financial abuse. The Jacob Reingold Institute at the Brookdale Center on Aging is considered a good example in this area. The institute undertook a survey of 200 case management and health care providers in New York City about their experiences with elder financial abuse. The study found that promoting the development and expansion of daily money management services could significantly reduce the problem of financial abuse of older people (NCPEA 2009). The Reingold Institute provides technical assistance and training materials to encourage agencies to set up money management services (Nerenberg 2006). A recent cost analysis study by the Reingold Institute reported significant cost savings when compared to alternatives such as Adult Protection Services (APS) and recommended inclusion of DMM as a
core component of case management services (Sacks et al. 2009).
Advocacy can provide older adults with an opportunity to express their concerns and experiences, and can support and enable people to make their own informed decisions (Anetzberger 2004, Kalaga et al. 2007). Empowerment is a central feature of advocacy. In practice, advocates can provide information, support and advice to older people about their rights and the range of services available to them (Kalaga et al. 2007). They may assist in setting up, facilitating or implementing plans for care or financial management (Podnieks 2008). Advocacy emphasises collaboration between older people and service providers and promotes the use of the least restrictive and intrusive interventions available (Wolfe 2003, Podnieks 2008).
Advocacy services may be provided by community-based organisations or are sometimes available through criminal justice systems, in the form of victim or witness assistance programmes (Dyer et al. 2005). For example, legal advocacy usually depends on an expert lawyer or police role focused on achieving a particular legal outcome (Cambridge and Parkes 2004b). Professional advocacy generally occurs within health or social care settings. However, this can create potential conflict between promoting the needs of the service user and the interests of the professional organisation within which the advocate works (Cambridge and Parkes 2004b). Podnieks (2008) argues that advocacy services should always be independent from formal service delivery systems. Citizen advocacy, in contrast, tends to involve unpaid advocates drawn from local communities who are independent from service agencies and often engage in longer term one-to-one relationships (Cambridge and Parkes 2004b). Peer advocacy may involve an advocate who has shared a similar experience. Finally, self-advocacy is driven by service users themselves and may involve direct action, personal empowerment and social justice.
Both formal and informal advocacy programmes are currently in operation in parts of Canada and the US (Podnieks 2008). Cripps (2001) describes the use of a rights-focused advocacy intervention to support older people to overcome situations of abuse in Australia. In this model elder abuse is seen as the denial of rights such as the right to make ones own decisions and the right to live free from fear of violence. An advocate is seen as an
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agent of change, assisting the older person to identify strengths in their existing and potential, formal and informal networks which may help to overcome abusive circumstances. In a retrospective analysis of 100 case records, the advocacy model was effective in enabling older people to stop the abuse in 50 percent of cases and in 34 percent of cases to allow clients to take some action towards stopping the abuse but not entirely preventing it.
The Mental Health Care and Treatment (Scotland) Act 2003 gives vulnerable adults in Scotland a legal right to advocacy services (Kalaga et al. 2007). However, the UK guidance document No Secrets called for a greater emphasis on the empowerment of vulnerable adults (Department of Health 2010).
A number of advocacy initiatives for older people have been established in Ireland in recent years, which may have a role in the prevention and management of elder abuse. The Cork Older Peoples Advocacy Service was set up in 1999 to train and give on-going support and supervision to volunteer advocates to help empower older people who have difficulty in expressing their needs and concerns or accessing services (Comhairle 2003). The Finglas Volunteer Peer Advocacy Programme was began in North Dublin in 2005 with a weekly training course for volunteers taking place over 9 weeks. This programme supported by Age Action Ireland offers older people independent information and support to resolve a wide range of problems (Dooley 2007). Similarly in North Dublin, the Dementia Rights Advocacy Project, established in March 2006, advocates for anyone in the area who has or may have dementia, dealing with issues such as family conflict, access to entitlements and risk of abuse (usually financial) (Edmond 2007). The impact or effectiveness of these programmes has not been evaluated. Funded by the HSE, an Advocacy Programme for Older People in Residential Care was set up in 2007 in response to media exposure to poor care practices in a Dublin nursing home. This programme was developed under the auspices of the National Advocacy Programme Alliance (NAPA). Its main aim is to provide an independent advocacy group for older people living in residential care settings. The programme comprises three core strands: Independent volunteer advocacy programme; training programme; and information programme. An evaluation of this programme was recently undertaken and findings proposed that the programme adopts a new organisational structure and be
located outside the HSE and instead within an organisation for older people in the community and voluntary sector. Third Age now assumes responsibility for the programme.
2.5.11 Mediation, Conflict Resolution and Restorative Justice
Restorative Justice is another approach, closely linked to the advocacy model of intervention, which has recently been explored to address cases of elder abuse (Nerenberg 2008). This approach conceptualises abuse as a violation of people and relationships rather than a violation of the law (Groh 2005). The focus is therefore on resolving conflict, working towards restoring or rebuilding relationships and repairing any harm done (Groh 2005, Podnieks 2008). This may include mediation, family conferencing, and dispute resolution (Podnieks 2008). Mediation from an independent source is considered an effective method for dealing with family disputes (Kalaga et al. 2007). In England, for example, the Office of Public Guardians may act as a mediator in family disputes, especially where they may put an older person at risk of financial abuse (Kalaga et al. 2007).
The Restorative Justice Approaches to Elder Abuse Project in Kitchener, Ontario, Canada is one example of an innovative restorative justice intervention model (Groh 2005). Funded over four and a half years, this project was intended to increase the communitys ability to respond to elder abuse and decrease older adults fears about reporting abuse by providing a safe and fair environment to address the abuse without involving the criminal justice system. The project was a collaboration between seven community agencies including health, justice, social services, ethno-cultural and faith organisations. Referrals to the project could be made by anyone, after which a screening process was used to establish if it was safe and appropriate to use such a model in the circumstances. The restorative justice approach assigns a trained and skilled facilitator to both the victim and perpetrator of abuse. Individual counselling may be required for either or both parties before the facilitators eventually bring them together at a conference or circle where they attempt to reach consensus about how and why the abusive situation occurred and how to prevent future mistreatment. Anecdotal feedback has been positive regarding this intervention but full evaluation data was not identified (Groh 2005).
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One rationale for this collaborative approach may be supported on the basis that in many instances the perpetrator of abuse is also a caregiver or family member and may be the only source of emotional, physical and financial support for the older victim (Parra-Cardona et al. 2007). However, restorative justice approaches usually involve a time-consuming and costly process, and concerns have been raised over the potential to re-victimise the older people involved (Podnieks 2008).
2.5.12 Legal Intervention
Legal interventions in cases of elder abuse may make use of both the criminal and civil justice system (Kalaga et al. 2007). Civil law remedies can be used against actual or potential perpetrators of abuse. These may include protection or restraining orders as well as the appointment of powers of attorneys, public guardians or other surrogate decision-makers, where mental capacity is lacking. Further civil law actions include emergency removal orders or involuntary mental health placements as well as securing of assets or freezing of estates (Dyer et al. 2005, Kalaga et al. 2007). Criminal laws sanction the prosecution of individuals accused of a criminal offence (Kalaga et al. 2007).
One of the most striking changes in the field of elder abuse in the US in recent years has been the increasing numbers of prosecutions and charges filed in cases of abuse (Bonnie and Wallace 2003). This has been attributed to new legislative instruments and procedures as well as improved training for law enforcement officers and prosecutors in working with older people (Nerenberg 2006). However, legal interventions are still used in only a small minority (approximately 7 percent) of cases nationally (Dyer et al. 2005). Interventions tend to fall along a continuum with respect to safety, protection and freedom from voluntary to involuntary interventions (Nerenberg 2008). Legal interventions are considered to be amongst the most restrictive interventions available and decisions to prosecute require complex judgements balancing protection against punishment and deterrent considerations (Bonnie and Wallace 2003, Dyer et al. 2005). Legal interventions are often derived from domestic violence models but remain controversial in terms of their application to elder abuse where circumstances may be complicated by a dependency relationship between the perpetrator of abuse and the older victim (Wolfe 2003, Pillemer et al. 2007).
The efficacy of criminal and civil justice interventions is also open to debate. A study by Filinson (1993) found that the recurrence rate for abuse was 24 percent for those who received assistance, support and advocacy in the use of the criminal justice system, compared to just 17 percent in a control group. However, the incidence of recurrence of abuse was unknown in 43 percent of the control cases compared to just 12 percent of the intervention cases (Ploeg et al. 2009). Furthermore, Brownell and Wolden (2002) found no statistical differences in case solution between groups who received a legal services programme and those who received a social services programme. More cases of financial abuse were successfully resolved with the legal service programme but only a small number of cases were assessed (Ploeg et al. 2009).
Mental capacity legislation is particularly pertinent in protecting older people from abuse, especially in terms of financial exploitation. These laws are generally designed to safeguard individuals who lack the capacity to make decisions for themselves regarding either their personal welfare or financial affairs. Some jurisdictions have court investigators to consider proposed guardians or power of attorneys and investigate allegations of abuse and intervene where necessary (Nerenberg 2006). The Mental Capacity Act 2005 covering England and Wales introduced a new criminal offence of neglect that can be charged against anyone who has mistreated or wilfully neglected a person who lacks capacity. Traditionally, legal guardianship has involved the permanent removal of a persons right to make their own decisions (Dyer et al. 2005). However, there is an increasing trend towards legislative reform to empower vulnerable adults to remain at the centre of decision-making as much as possible (Heath and Phair 2007).
2.5.13 Education, Information Provision and Advice
Qualitative research with older people who have been abused has found that they often do not know where to go for help, are unaware or unclear about their rights and entitlements, fear authorities in general and fear that services or agencies may not take them seriously (Pritchard 2000, Mowlam et al. 2007). Victims of elder abuse have identified a need for practical, accurate and reliable information on a range of issues including legal advice, income support, housing, family resources and
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financial support (Schaffer 1999, Pritchard 2000, Lafferty et al. forthcoming). A randomised control trial carried out in New York found no significant differences in knowledge of elder abuse, awareness of services or reports of new incidents of abuse, between an intervention group who received public education via community meetings, posters in public areas and distribution of leaflets and a control group who received no education (Davis and Medina-Ariza 2001, Davis et al. 2001). However it is worth noting that only 6 percent of elderly residents at the targeted housing projects attended the educational settings (Ploeg et al. 2009).
2.5.14 Multi-Component Interventions
Many researchers and practitioners now advocate the need for different models of intervention on the basis that no one model is likely to work for all older people (Podnieks 2008). It is increasingly recognised that the distinct causal factors and myriad manifestations of elder abuse, alongside differences in geography, culture and community size and structure necessitate diverse approaches to managing cases of elder abuse (Fitzgerald 2006, Nerenberg 2008, Perel-Levin 2008, Podnieks 2008). For example, many interventions draw strongly on experiences and approaches from the fields of domestic violence and child abuse (Wolfe 2003). However, it is questionable how easily translated and how relevant these models are in the context of elder abuse (Podnieks 2008). Domestic violence approaches may not, for instance, be appropriate in circumstances of neglect (OLoughlin and Duggan 1998). Specific interventions therefore need to be multi-layered and determined based on factors such as the type and duration of mistreatment, the willingness of the victim or abuser to accept help and the safety risk to the intervening professional (OLoughlin and Duggan 1998, Anetzberger 2004, Kalaga et al. 2007). The service needs of both victim and perpetrator may span a broad spectrum and interventions and should therefore be context specific (Lachs and Pillemer 2004, Nerenberg 2006).
Elder abuse is frequently described as a complex phenomenon with multiple causes and a myriad of different outcomes (Nerenberg 2008). For example interventions that respond only to the older person and fail to address the needs of the family unit may result in the abuse recurring, particularly where functional dependence or a family history of abuse are factors (Pratt
et al. 1983). There is increasing support for the application of an ecological model for elder abuse. This model conceptualises abuse as the result of the complex interplay between a persons individual characteristics, interpersonal relationships as well as the characteristics of the community in which they live and societal factors, such as policies and social norms (Perel-Levin 2008). According to such a model, a holistic, multi-component approach to intervention, addressing a range of causal factors and incorporating a variety of services, is more likely to be effective (Pillemer et al. 2007, Nerenberg 2008, Perel-Levin 2008).
2.6 Outcomes and Case ClosureStudies examining the impact of interventions employed in the management of elder abuse cases have used many different measures of outcome. These include recurrence of abuse and cessation or reduction in the level of abuse experienced by victims or perpetrated by abusers (Wilson and Micucci 2003, Ploeg et al. 2009). Some studies have also examined rates of relocation, institutionalisation or even death as an outcome. Research undertaken in Australia, for example, found that 65 percent of cases had resulted in institutionalisation three years after they were identified (Kurrle 1993). Similarly, a UK study found that the majority of victims whose abuse was reported and substantiated ended up being institutionalised or dying (Wilson 2004).
Another method of measuring outcomes in elder abuse intervention studies has been the proportion of cases classified in social service records as closed or resolved (Ploeg et al. 2009). Wolf and Pillemer (2000) found that a reduction in the severity and frequency of abuse was correlated with case resolution. Outcome measures in elder abuse cases are often difficult to ascertain and decision-making regarding case closure often relies on subjective judgements such as safe and stable or a lot resolved, or about the same (Wilson and Micucci 2003). According to social service workers in a study by Cambridge and Parkes (2004b), practitioners in adult protection cases must have the ability to manage sometimes untidy endings.
A study by Neale et al. (1997) explored the reasons given by professionals for closing a case documented in computerised records. One third of closures followed the death or relocation of the older person. A further 12.3
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percent of cases were closed because the victim refused services and 14.2 percent because 12 months had elapsed without further incidents of abuse. In 34.5 percent of closed cases a professional had reassessed the case and deemed the individual to be at a low risk of further abuse. As these findings illustrate, it is not always possible to achieve a satisfactory outcome. In some cases complex relationships and ill-health hinder successful case resolution (Killick and Taylor 2009). In cases where a client refuses services, social workers may struggle with the awareness that in spite of the case being closed the abuse is likely to recur (Dayton 2005). Donovan and Regehr (2010) suggest that follow up or monitoring may be necessary in many cases. This difficulty will be discussed in more detail in section 2.8 in terms of the ethical dilemmas often faced by case workers in their
decision-making and their case management.
2.7 Collaboration, Multi-disciplinary and Interagency Working By far the